Coroner writes to NHS England bosses after death of Preston man wrongly told ambulance was on its way

A good Samaritan who called 999 after his suicidal friend self-harmed inadvertently left him to die after wrongly being told an ambulance was en route, an inquest has been told.

James Paul Michael Masheter’s friends rallied around him after he called them to say he was “dying”, with one concerned pal turning up at the 42-year-old’s home in Hoyles Lane, Cottam, to help look after him until professional help arrived.

Preston-born Masheter, who had a history of ill mental health and self-harming, and who had been through a recent break-up and was having money troubles, was distressed and bleeding from superficial wounds on March 31 2024.

Four 999 calls were made that evening – with the unnamed friend leaving after being told an ambulance would be there “imminently”, a hearing held to establish the circumstances of Masheter’s death was told.

But the waiting time information was duff and no ambulance actually arrived until 8.10am the next day, with its crew finding Masheter dead inside his home.

Kate Bisset, coroner for Lancashire and Blackburn with Darwen, has now written to bosses at NHS England to tell of her concerns.

In her letter, which was also sent to the North West Ambulance Service (NWAS), which has apologised, and Masheter’s family, she writes: “Due to demands of the service, there were significant delays in ambulance allocation but Mr Masheter’s friend was told that that delay was significantly less than was the case.

“Incorrect information about the waiting times for ambulance attendance was provided to Mr Masheter’s friend and this contributed to his death.”

Bisset specifically criticised the NHS Pathways system used to triage patients.

The pathway sees emergency service operators ask scripted questions to determine the seriousness of a call, including whether the patient is awake and breathing.

But questions for mental health calls are “limited”, the coroner said, adding that it is “not clear” to her “whether it is possible for serious mental health crisis situations which present a risk to life (to be) capable of being properly risk assessed on the basis of the NHS Pathways mental health triage which exists at present”.

Masheter was treated as a category three patient on each of the four times the ambulance service was contacted on the eve of his death. The “urgent” categorisation means paramedics should arrive on the scene within 120 minutes “at least nine out of 10 times”.

There are four categories, including:

One, for life-threatening injuries and illnesses, with an average response time target of seven minutes and within 15 minutes nine in 10 times;
Two, for emergency calls, with an average response time target of 18 minutes and within 40 minutes nine in 10 times; and
Four, for less urgent calls, with a response time target of within 180 minutes at least nine in 10 times, though callers may instead be given telephone advice or referred to another service such as a GP or pharmacist.

While Bisset’s report does not say when exactly each 999 call was made in Masheter’s case, timings suggest it took more than eight hours for an ambulance to turn up.

NHS England has until May 30 to respond to Bisset’s letter. It must say what action it has taken or will take – or explain why nothing will be done.

Masheter’s funeral was held at St Andrew & Blessed George Haydock Catholic Church in Cottam on April 19 last year, followed by a wake at the Lonsdale Social Club in Preston.

An online obituary includes a photograph that appears to show him raising his arms in victory inside a boxing ring. The announcement includes the words: “Loving you always, forgetting you never.”

Donations to the Mary O’Gara Foundation, a suicide prevention, awareness and education charity based in Fulwood, were being accepted in lieu of flowers.

NWAS and NHS England were contacted for a comment.

An NWAS spokesperson said: “We offer our sincere condolences to James’s family and apologise for not responding to him quickly enough.

“We have carried out our internal investigation and will now review the regulation response in light of the coroner’s concerns.”

NHS England did not respond by the time of publication.

Blog Preston contacted Dignity Funeral Directors, which announced Masheter’s death, in a bid to contact his family prior to publication.

This article first appeared on The Lancashire Lead.

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